My doctor has prescribed a particular medicine for me, but my health plan says it’s not on the plan’s formulary. What does that mean?
All of our health plans use formularies. Formularies are lists of drugs the health plan prefers that you take for various illnesses. Each health plan has its own formulary, so a drug may be on the formulary of one plan, but not on another. These drugs cost less for the health plan to dispense because they are purchased in bulk with special discounted pricing from the manufacturer. A&M System health plans, including the A&M Care plans, have a three or four-tier copayment system. These consists of three or four copayment levels with the lowest copayment for a generic drug, a higher copayment for a brand-name drug on the formulary, and a higher copayment for a brand-name drug not on the formulary, and in some cases, a coinsurance amount for very expensive injectables or biogenetic drugs. The formulary may change during the year, but the Texas Department of Insurance now requires health plans to notify you 90 days in advance if they will be removing a drug you are taking from the formulary
